HMO vs PPO with Independence Blue Cross

Specialty Drug Coverage Through Employer Insurance

For employees, insurance coverage depends on the benefit plan being used. Employer sponsored benefits provide various ranges of insurance coverage. Specialty drugs, or specialty pharmaceuticals can cost up to $2,000, making them some of the costliest prescriptions. These drugs are not available at all pharmacies and are commonly used to treat chronic complex conditions such as:

  • Cancer;
  • Multiple sclerosis;
  • Rheumatoid arthritis;
  • HIV/AID;
  • Pulmonary hypertension; and
  • Hepatitis B and C.

Sourcing and Manufacturing

Pharmaceutical drugs are expensive as they are specially sourced and require special care and handling. Many are biologics, which target proteins or cells in the body to block other inflammatory and damaging cells. These drugs are sourced from natural resources including sugars and proteins as well as plants, animals, and microorganisms.  Due to the complexity, specialty drugs are generally more expensive and can be harder to obtain through pharmacies.

Coverage & Administration

Whether these drugs are covered by insurance depends on the coverage offered through the elected plan. Pharmaceutical drugs or pills that are administered at home are likely to be covered under prescription drug benefits. If administration is through a doctor’s office or outpatient medical center, pharmaceutical drugs or pills are likely to be covered through medical benefits.

Administration of specialty drugs can happen in varying periods of weeks or months.  With the complexity of these drugs, routine monitoring and testing can be ongoing to monitor progression and side effects. They are administered by select pharmacies and require FDA-mandated monitoring, as compared to non-specialty medications that can be administered through retail and mail order pharmacies. It is important to note that specialty medications are often required to have prior authorizations to obtain insurance coverage.

 

If you have questions about the coverage of your specialty prescriptions, please speak with your dedicated Creative Benefits ESR team to review your options.